Business Analyst, Clinical & Reimbursement Policy

Job description

At Clover Health, we’re focused on improving the health of our members by leveraging technology and data-driven insights to provide personalized, high-quality care. As a Medicare Advantage plan, we aim to empower our members by helping them navigate the complexities of healthcare and live healthier lives. We are passionate about making healthcare easier, more affordable, and more accessible for everyone. We are looking for an AI-forward Business Analyst, Clinical & Reimbursement Policy to serve as the strategic bridge between regulatory requirements and automated execution. In this high-impact role, you will be responsible for the end-to-end lifecycle of Clover’s clinical and reimbursement policies, ensuring they are accurately interpreted, regularly updated, and seamlessly integrated into our claims environment. You will act as a primary Subject Matter Expert (SME), translating complex Medicare guidelines—including National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)—into actionable logic. You will also play a critical role in vendor management, partnering with external vendors to enhance policy oversight. Your mission is to accelerate Clover's transition toward a high-precision payment ecosystem where monitoring and research are highly automated, ensuring clinical and reimbursement policies are seamlessly and accurately operationalized. As a Business Analyst, Clinical & Reimbursement Policy, you will: Policy Lifecycle & Compliance: Own the accountability for the development and maintenance of clinical and reimbursement policies, ensuring perfect alignment with CMS regulations. Medicare Regulatory SME: Serve as the authority on Medicare guidelines, specifically interpreting and operationalizing NCDs, LCDs, and general national coding guidelines. Strategic Vendor Management: Serve as the primary oversight for external vendor performance regarding policy monitoring and accuracy. Hold partners to world-class standards through data-driven performance reviews and collaborative workflow design. AI-Driven Evolution: Lead the implementation of AI initiatives to automate the monitoring of reimbursement policies. Utilize advanced LLMs (such as Claude, Gemini, and ChatGPT) to conduct regular deep research on ongoing industry trends. System Integration: Partner with the Configuration and Data Science teams to ensure that clinical and reimbu…